Provider Directories Speak Volumes About How Insurers Feel About Healthcare Consumerism

When I was the news editor and then editor of a healthcare business publication, the three-part test for any big controversial story was accuracy, balance and fairness. Was it right? Did it cover both sides of a conflict? And did it give both sides in the conflict an opportunity to respond?

The most important of these is accuracy. I would tell our reporters, “You can say anything about anyone as long as it’s accurate. Truth is the ultimate defense.”

It’s journalism’s version of the Biblical trilogy of faith, hope and love with the greatest being love.

Accuracy is a pillar of healthcare consumerism. It’s the most important pillar. If we want patients and members to make informed decisions about their medical care and their health insurance, they need accurate information to make the right choices for them.

Unfortunately, providers and payers aren’t too good — accidentally, ignorantly or deliberately — at giving patients and members accurate information to make informed decisions. It’s never been a priority, but it’s never been more important. Witness all the hospital foot-dragging on posting their prices online for consumers to understand as required by the federal price transparency rules.

A recent study in the Journal of the American Medical Association illustrates how far payers, too, have to go in helping their members be effective healthcare consumers.

Three researchers, including two physician researchers affiliated with the University of Colorado School of Medicine, wanted to know one simple thing: Is the address and specialty of the same physician listed accurately in the directories of commercial health insurance companies? Basic stuff that should be easy. Remember phone books? The Yellow Pages?

The researchers’ study pool was about 635,000 doctors and the physician directories of five commercial health insurance companies: UnitedHealth, Elevance, Cigna, Aetna and Humana. The study period was September 2022.

Of the individual doctors, nearly 450,000, or more than 7 out of 10, were listed in multiple provider directories. Of the physicians in multiple directories, only 19.4% had their addresses and their specialties entered consistently across the directories. In other words, more than 80% of the doctors’ entries were inconsistent — or, as I like to say, wrong. And the more directories they were in, the worse it got:

• 71.4% of addresses and specialties were inconsistent if they were in two directories.
• 79.3% of addresses and specialties were inconsistent if they were in three directories.
• 86.0% of addresses and specialties were inconsistent if they were in four directories.
• 92.2% of addresses and specialties were inconsistent if they were in five directories.

Here’s the researchers’ takeaway on insurers getting basic information about their doctors wrong, in addition to getting a surprise bill from an out-of-network doctor: “Inaccurate physician directories can lead to delays in care due to difficulty finding the correct physician, challenges in regulators assessing health insurer network adequacy, and misrepresentation of network depth and breadth as consumers select health plans.”

The researchers gave insurers and doctors the benefit of the doubt as to why directories are so wrong: “The challenges for insurers to build and maintain accurate physician directories stem from frequent changes and lack of a uniform standard. Additionally, the administrative burden for physician practices to send directory updates to insurers via disparate technologies, schedules, and formats costs practices a collective $2.76 billion annually.”

Here’s my take: Members are screwed.

If getting the addresses and medical specialties of doctors right to help consumers was as important to health insurers and physicians as getting coding, billing and claims right, this wouldn’t be a problem. But it’s not, so it is.

It’s spelling. It’s fact-checking. We even have computers and software now that can help with both.

What will it take to get provider directories right? The researchers recommended using technology to build a single, centralized physician directory run by CMS. A single source of truth as tech vendors like to say. Copy and paste. Click and drag.

If not, it’s smile and wave to healthcare consumerism.

Thanks for reading.